1578758652 NPI number — MS. MARY ELIZABETH BECKLEY CLARK LMSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578758652 NPI number — MS. MARY ELIZABETH BECKLEY CLARK LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BECKLEY CLARK
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BECKLEY
Provider Other First Name:
MARY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MASTERS SOCIALWORKER
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578758652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
801 HAZEN STREET SUITE C
Provider Business Mailing Address City Name:
PAW PAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49079-0249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-657-5574
Provider Business Mailing Address Fax Number:
269-657-3474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57418 CR 681
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-621-6251
Provider Business Practice Location Address Fax Number:
269-621-6044
Provider Enumeration Date:
09/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6801078536 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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